Attention-deficit hyperactivity disorder in ancient Greece: The Obtuse Man of Theophrastus

Abstract

We present an ancient Greek description written by the philosopher Theophrastus in his classic book ‘Characters’ comparable with modern attention-deficit hyperactivity disorder. The arguments are based in one chapter of this book—The Obtuse Man—presenting features of a character closely resembling the modern description of attention-deficit hyperactivity disorder. In a free comparative exercise, we compared Theophrastus descriptions with modern Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) attention-deficit hyperactivity disorder symptoms. The sentences describing The Obtuse Man written by Theophrastus are similar to several symptoms of attention-deficit hyperactivity disorder and he would probably be currently diagnosed with this disorder as an adult. To our knowledge, this is the oldest description compatible with the current conception of attention-deficit hyperactivity disorder in adults in the Western literature. Differently than the moralistic view of ancient Greece regarding those symptoms, the medical attention-deficit hyperactivity disorder conception may be advantageous to patients since it might reduce prejudice and allow individuals to seek treatment.

Introduction

Attention-deficit hyperactivity disorder (ADHD) is a neuropsychiatric condition characterized by the presence of symptoms of inattention and/or hyperactivity/impulsivity, according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association (APA), 2013). It is considered a valid and common psychiatric disorder in children, adolescents and adults (Faraone, 2005). Extensive literature shows that genetic and neurobiological underpinnings are responsible for the symptoms, as well as clinical impairment in several life areas, which can be mitigated with pharmacological and psychosocial approaches (Faraone, 2005; Gallo and Posner, 2016). Despite being one of the most studied disorders in psychiatry, ADHD is still criticized in lay and professional literature as an artificial label (Bowden, 2014; Moncrieff and Timimi, 2013). Critics suggest that the current diagnosis of ADHD is mainly related to adverse living conditions in Western Society, such as pressure for performance. Others believe that this labeling also works in service of the pharmaceutical industry (Moncrieff and Timimi, 2010).

Historical references demonstrating that characteristics resembling ADHD were observable in different historical times could help to clarify this debate (Taylor, 2011). Moreover, descriptions made before the appearance of modern Western Society and its political, economic and nosological conceptions would be important to reinforce the validity of the current ADHD concept, thereby preventing social stigma. In this sense, there are historical descriptions of pictures resembling ADHD published in a period when the social factors and context were deeply different from those currently acting (Taylor, 2011).

The few historical texts in the literature that describe pictures compatible with what is currently considered ADHD were written in both scientific format and folk or fictional literature (Barkley and Peters, 2012; Taylor, 2011). Until recently, two publications disputed the title of ADHD’s first description: the fictional and worldwide known ‘Struwwelpeter’ written by the pediatrician Heinrich Hoffmann in 1845 (Hoffmann, 1845) and the 1902 ‘Goulstonian Lectures’ titled ‘An abnormal psychical condition in children’, presented by George F. Still and published in The Lancet (Still, 1902). The first contains a series of illustrated short poetic narratives, with one of them telling the history of a boy that, due to his distraction and daydreaming, fell in a river and drowned. In the latter, Still (1902) described in detail 13 children presenting normal intelligence, but behavioral and attention problems caused by what the author called ‘lack of moral control’. More recently, a text written in 1798 by the Scottish physician Alexander Crichton titled ‘An inquiry into the nature and origin of mental derangement: comprehending a concise system of physiology and pathology of the human mind and a history of the passion and their effects’ was rediscovered and republished (Palmer and Finger, 2001). Crichton described a clinical picture similar to the current concept of the predominantly inattentive presentation of ADHD in adults. Soon after, Barkley and Peters (2012) published an article claiming to have found an even older medical description of attention disorders, written by the German physician Melchior Adam Weikard in his medical textbook from 1775 (Barkley and Peters, 2012). He described children and adults who were distractible, with poor persistence, overactive and impulsive.

Considering that behavior, feelings and cognition are relevant traits to understand and predict human conduct, they have been the topic of frequent descriptions along history. The roots of the western concepts of mind and mental illness could be attributed to ancient Greeks poets and philosophers (700–300 bc). They were responsible for the epistemological evolution, where reason and scientific views became gradually predominant in western culture over the poetic approach. In this sense, explanations for the origins of the soul, mind and madness could be divided in three main models: (a) the poetic model, as described in the Homeric poems, that considered mythological and external forces responsible for human behavior; (b) the philosophical model, best represented in the Plato work, in which behavior results from the constant struggle between reason (soul) and appetite (body); and (c) the medical model of Hippocrates, that is considered the more ‘scientific’ approach, where behavior and its disorders had their origin in the brain (Simon and Weiner, 1966).

In this article, we present an ancient Greek description compatible with modern ADHD written by the Socratic philosopher Theophrastus in his classic book ‘Characters’ in the fourth century bc. We also draw a parallel between the ancient Greek view and current medical ADHD conceptions. As far as we know, this is probably the oldest description of a picture closely resembling the current conception of ADHD in adults.

The ‘Characters’

Apart from illnesses that have been reported since ancient Greece, other milder conditions, which can currently be described as mental disorders, were not generally considered as diseases at that time. Even so, these conditions could have been perceived as sufficiently relevant to be described in non-medical Greek texts as odd or picturesque persons. One notable example of these descriptions can be found in the book ‘Characters’ by Theophrastus.

Theophrastus (371 bc Eresos – 287 bc Athens) was one of Aristotle’s followers. His name had originally been Tyrtanius, but Aristotle changed it to Theophrastus (‘divine diction’) in recognition of his great eloquence (Diggle, 2004). The work ‘Characters’ is a collection of 30 short character-sketches depicting different types of individuals living in Athens in the late fourth century bc. The exact purpose of the book is unknown; it may have been written initially just for amusement, but it was later probably used for educational purposes (Diggle, 2004). Each type is described in a succinct and objective style, usually in 10–15 phrases, and depicts individuals presenting reprehensible patterns of behavior. These individuals could easily be found today, if the actions described were culturally adapted to modern times. The Talker, The Shameless, The Repulsive, The Coward and The Arrogant Man are some chapters of the book. The 14th character described is The Obtuse Man (see Box 1), according to the translation by Diggle (2004).

Box 1.

The comparison between Theophrastus’ description and the modern conceptualization of ADHD.

XIV. The Obtuse Man (αναίσθητος—Anaisthetos)‘Obtuseness may be defined as slowness of mind in speech and action1. The Obtuse Man is the kind who does a calculation with his counters2 and after computing the total asks the person sitting next to him “What does it come to?” (A). When he has a lawsuit to defend and should be going to court he forgets about it and goes into the country (B). At the theatre he is found asleep in his seat when the audience has left (C). After a large supper he is bitten by his neighbour’s dog when he gets up and goes to the lavatory during the night (D). He searches for some item that he has acquired and he is unable to find it, even though he stored it away himself (E). When a message arrives notifying him of the death of a friend and inviting him to the funeral, his face darkens and he bursts into tears and says “And the best of luck to him!” (F). He is also apt to get witnesses to support him when he is taking repayment of money that is owed him3 (G). He is annoyed with his slave for not buying cucumbers during the winter4 (H). He tires out his children by forcing them to wrestle and run races with him (I). In the country […]5 when he is boiling lentil soup he puts salt into the pan twice and makes it inedible (J). If it is raining he says “How sweetly the stars smell,” when everyone else says “the earth”6 (K). When someone remarks “You can’t imagine how many bodies have been taken out to the cemetery through the Erian Gates,”7 he answers “I wish you and I could have such a windfall” (L)’.

Comments:1. Authors dispute the authenticity of this introductory definition.2. Used in abacus calculations.3. It was natural to Athenians to have witnesses when making a loan or repayment. The payer needs proof that he has paid. But the recipient does not need to call witnesses to proof that he has been paid.4. Cucumbers are a summer crop.5. The text may be lacunose, with ‘in the country’ the beginning of a lost sentence.6. He says ‘stars’ instead of ‘earth’, using a word that is different from the right one: a verbal mistake.7. This gate is unknown; maybe it could be in the northwest of the city wall, on the road to a large cemetery

Comparing the description of Theophrastus and current symptoms views:a. DSM-5 ADHD symptoms: Inattention: B, E, G and J; Hyperactivity: Ib. Executive dysfunction: A and Hc. Sleep problems: C and D.d. Poor communication skills: F, K and L

DSM-5: Diagnostic and Statistical Manual of Mental Disorders (5th ed.); ADHD: attention-deficit hyperactivity disorder.

The Obtuse Man—comments on the character

Theophrastus’ 14th character is named The Obtuse Man (Anaisthetos—αναίσθητος). The noun anaisthisía (αναισθησία) and the adjective anaisthetos (αναίσθητος) come from the verb aisthánomai (αἰσθάνομαι), which means ‘see, note, learn something through the senses’, but with a prefix denoting reverse meaning. Therefore, ‘Anaisthetos’ could be literally translated as ‘lack of apperception’ (Diggle, 2004).

In the book, The Obtuse Man is initially defined as having ‘slowness of mind, speech and action’. From then on, Theophrastus describes The Obtuse Man in 12 objective sentences, which resemble the presentation of ADHD symptoms currently observed in DSM-5 criteria (APA, 2013). In a free comparative exercise, it is possible to relate the ‘symptoms’ described by Theophrastus as follows: items B, E, G and J would likely be classified by current clinical psychiatrists as inattentive symptoms. Item H could also be considered an attention mistake, as the individual forgets there are no cucumbers in winter season. Similarly, item I could be clearly classified as a hyperactive symptom. Item A is particularly interesting because it shows that The Obtuse Man is able to perform a calculation correctly; however, he still needs external confirmation on what he is doing. This fact partly contradicts the definition of ‘slowness of mind’ presented in the first phrase of the character. Considering that he has enough intelligence to perform mathematical calculations, what Theophrastus could be highlighting in item A is not in fact ‘slowness’, but the immediate loss of attention in the task.

In three other items (F, K and L), Theophrastus mentions The Obtuse Man’s speech. His dislocated comments have in common the fact that they are verbally impulsive and inappropriate, inconsistent with what would be socially correct or acceptable. This can be observed as following: F—‘And the best of luck to him!’ (for a dead friend); K—‘How sweetly the stars smell’ (when everyone else says ‘the earth’); and L—‘I wish you and I could have such a windfall’ (the good fortune to die?). The individual responds impulsively and erroneously after processing an input of a message (F), a sensory impression (K) and a question from someone else (L). There is no mention in the text to the individual’s own reaction to what he has just said, if he notices or corrects his mistake. Such information would allow a better judgment about the origin of these comments, if they would be related to impulsivity and inattention, to speech itself, to common mistakes or even to cognitive limitations. Interestingly, pragmatic language difficulties have already been reported in children, adolescents and young adults with ADHD (Green et al., 2014; Korrel et al., 2017).

The item C seems associated with somnolence and could be related to a sleep disorder. The item D could also be associated with sleepiness, but admits alternative explanations, including those related to inattention. The Athenian ‘bathroom’ was a tank located on the roof of some houses or sometimes out of them (Diggle, 2004), and The Obtuse Man could have taken a wrong path because of his inattention or sleepiness and ended up in the neighbor’s yard, where he was bitten. It is noteworthy that sleep problems are also frequently reported by individuals with ADHD (Yoon et al., 2012).

An alternative explanation for the characteristics of The Obtuse Man depicted by Theophrastus could be mild intellectual disability. Some items, such as F, K and L (inappropriate comments) or lack of knowledge on item H (cucumbers) could be related to low intellectual capacities or executive functions. Nonetheless, there are some arguments against the mild intellectual disability hypothesis. The Obtuse Man fumbles, is unaware, is verbally inappropriate and does not handle the information from his surroundings as quickly or accurately as others, but it is not stated that he cannot learn. He apparently has the same social status as his fellow citizens, has a family, slaves and business. In fact, he is able to perform mathematical calculations and fully participates in the fourth century bc. Athenian social life, demonstrating that he likely suffered from what is currently known as executive dysfunctions (e.g. diminished working memory). Individuals presenting moderate or severe intellectual disability would likely not be considered as full citizens in ancient Greece (Milns, 1986). Furthermore, ADHD diagnosis and mild intellectual disability are not mutually exclusive (Xenitidis et al., 2010).

Discussion

Theophrastus’ The Obtuse Man seems to be the oldest detailed description of an individual with a chronic pattern of attention problems. The Obtuse Man was forgetful, inattentive and hyperactive, characterized by a general ‘lack of apperception’ (Anaisthetos) to events in his environment. These features, which nowadays could be considered as traits, compromised his mental abilities and impaired his quality of life. The Obtuse Man could probably be diagnosed as an adult with ADHD by current psychiatrists. Considering that the initial scientific description of ADHD comprised only children and adolescents (Still, 1902), it is certainly interesting that the oldest historical observation of an individual with ADHD characteristics had occurred in an adult. The presence of The Obtuse Man among the 30 Theophrastus’ ‘Characters’ also reinforces the idea that ADHD-like symptoms were relatively common in ancient Athens to deserve a description of a prominent philosopher.

It is worth adding that the 10th character, The Surly Man, would probably be currently classified as a dysthymic individual, reinforcing the idea that current milder psychiatric disorders or traits were not considered as medical problems by the Socratic school of philosophers (in which Theophrastus was inserted) but instead judged as a reprehensible pattern of personality, resulting from the lack of rational control over appetites and behavior (Simon and Weiner, 1966).

The Obtuse Man, in Theophrastus point of view, participated fully, albeit with difficulties, in ancient Greek social life, but was apparently seen as a morally reprehensible and weak citizen (or a negative example). The critique on these specific characteristics lasted two millennia, given that the conceptualization of ADHD, originally designated as ‘minimal brain dysfunction’, as an explanation for these symptoms in adults is very recent (Wood et al., 1976). Until then, individuals presenting such characteristics were socially criticized, but they were neither recognized as suffering from a psychiatric disorder nor treated.

The concepts of health and mental illness are influenced by cultural values of each time and we cannot assure that the current ADHD description is totally devoid of social influences in its design (Bowden, 2014). Currently, specific symptoms and impairment are considered criteria to validate a mental disorder (APA, 2013; Faraone, 2005). In this regard, it is interesting to note that the features described by Theophrastus in ancient Greece apparently brought impairment, prejudice and disapproval to these individuals. The Obtuse Man’s description allows us to infer that many typical ADHD symptoms were related to impairment even in a quite different historical context. From ancient Greece until today, subjects presenting ADHD-like symptoms suffer stigma and prejudice due to their behavioral traits (Thompson and Lefler, 2016). Conversely, the advances in psychiatry considering these problems as nosological entities seem advantageous while providing these individuals with the possibility of appropriate and effective treatment instead of being morally criticized. The same rational process occurred when Hippocrates postulated that several mental problems were illnesses and not products of divine vengeance. Strengthening our current nosological conceptions may result in better clinical care, treatment adherence and general outcomes. The abandonment of the medical concept of ADHD proposed by some critics could, as a consequence, result in a return to the helplessness of Theophrastus’ times. When current authors deny the existence of the disorder, they also deny their treatment, transferring to the affected individuals the responsibility for the management of their personal characteristics.

This work should be appraised in the context of some limitations. First, although some links between the characteristics of The Obtuse Man and his cultural context were made, it is beyond the scope of this study to profoundly discuss moral aspects of ancient Greece. Second, interpreting ancient texts regarding psychological traits requires caution, being intrinsically difficult to properly assure that some of the symptoms reported by Theophrastus are in fact related to ADHD. This occurs because the description of The Obtuse Man in a few sentences is laconic and incomplete, sometimes allowing multiple interpretations. However, the exhibited characteristics, if interpreted with some freedom, may allow these diagnostic speculations and many of the described features are undoubtedly similar to current ADHD symptomatology.

In conclusion, we suggest that Theophrastus’ description of The Obtuse Man recedes in two millennia the first known cultural description of an individual with ADHD-like characteristics and resembling what currently could be classified as an adult with ADHD. The social disadvantage arising from these ADHD-like symptoms even in a different cultural and temporal context is evident. The current medical approach to ADHD may be advantageous to patients in relation to the moralistic and divine approaches previously employed by ancient Greeks, since it might reduce prejudice and allow individuals to seek an adequate treatment.